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Download Patient Form - Anjali Goel MD
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INTAKE FORM Your name: __________________________________ Your email: __________________________________ Your phone: __________________________________ Best way to reach you? Email Phone Patient Information NAME________________________________________________________ HOME ADDRESS______________________________________________ CITY_______________________________STATE_________ ZIP CODE ____________ DATE OF BIRTH_____/______/______ AGE_________GENDER_________ Social History Parent’s Name _____________________________OCCUPATION___________________ Parent’s Name _____________________________OCCUPATION____________________ Is your child adopted? YES If yes, at what age? __________ NO If yes, does he/she know of the adoption? __________ Please list all persons living in the home with your child. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ How long have parents been: Married:________ Separated______________ Divorced________________ Living Together____________________ If parents separated or divorced please describe custody and visitation rights: ________________________________________________________________ If married please describe current relationship: _______________________________________________________________________ Tell Me About Your Child Please list your child’s strengths: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Diagnosis or explanations given to you about your child: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Being as descriptive as possible please describe your child to me: _________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ When did you first notice your child’s problem, what did you notice and was there an event that you think might have contributed? _________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Primary Care Physician Name _________________________________________________________ Address________________________________________________________ Phone _________________________________________________________ Therapist Name__________________________________________________________ Address________________________________________________________ Phone__________________________________________________________ Other Name __________________________________________________________ Address_________________________________________________________ Phone___________________________________________________________ Current Medication List Please bring ALL of your current medications with you for your initial appointment. _______Check here if your child does currently does not take any medications. MEDICATION _______________________ DOSE _____________________________ FREQUENCY _______________________ REASON___________________________ MEDICATION _______________________ DOSE _____________________________ FREQUENCY _______________________ REASON___________________________ CURRENT SUPPLEMENT LIST __________________________________________________________________________ __________________________________________________________________________ _________________________________________________________________________ MEDICATION ALLERGIES PAST MEDICATIONS Please recall any psychiatric medications that your child has taken in the past and their positive/negative effects. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Medical History Current Medical Problems __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Birth and Infancy History Was your child premature: Yes/No Number of weeks early?____________ Describe your child’s early temperament? _________________________________________________________________________ _________________________________________________________________________ Did either parent or primary care givers have difficulty with depression after the birth of your child? __________________________________________________________________________ __________________________________________________________________________ Emotional Development Circle all that apply to your child as a toddler or preschooler: Adaptable Able to play alone Frequent Temper Outbursts Difficulty with attention Impulsive Difficulty in interaction with others Fearful Sleeping difficulties Responds well to challenges Slow to warm up Easily Frustrated Sensitive/Empathic Easy to manage Difficulty with change Eating Difficulties Curious Angry Overactive Obsessive Sad Aggressive Moody Affectionate Current personality _____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Has your child ever been the victim of: Physical abuse Verbal abuse Sexual abuse Neglect ____no ____no ____no ____no ____yes ____yes ____yes ____yes Please note any significant events that have occurred within your family and briefly describe: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ School History School_________________________________________________________ Current grade______________________ Academic Achievement (circle one): Above Average Below Average Average Failing Does your child have a known Learning Disability? If so please describe: ________________________________________________________________________ ________________________________________________________________________ What are your child’s strengths in school? Where are they having difficulty if any? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Sleep History Any problems falling asleep? YES NO Any problems staying asleep? YES NO Any problems waking up? YES NO On average, how many hours of sleep does your child sleep per night? _______ Any history of: SLEEPWALKING YES NO SLEEP TALKING YES NO NIGHTMARES YES NO NIGHT TERRORS YES NO SLEEP APNEA YES NO TEETH GRINDING YES NO HEAVY SNORING YES NO Nutritional History Known allergies to foods? (please list) 1_________________ 2_________________ 3_________________ 4_________________ Suspected sensitivities to foods? (please list) 1_________________ 2_________________ 3_________________ 4_________________ Food cravings? (foods your child could not go without) 1_________________ 2_________________ 3_________________ 4_________________ Has your child ever been on a gluten-free diet? YES If yes, please list the results: _______________________________________________________ NO Has your child ever been on a casein-free diet? YES If yes, please list the results: _______________________________________________________ NO Which of the following best describes your child’s diet? ❒ Mostly carbohydrates (bread, pasta, etc...) ❒ Mostly dairy (milk, cheese, etc...) ❒ Mostly fast food. ❒ Mostly meat. ❒ Mostly vegetarian. ❒ Other – Describe: Spiritual Orientation Please list your family’s spiritual orientation or religion? ________________________________________________________________ ________________________________________________________________ How active are these beliefs in your life? ________________________________________________________________ ________________________________________________________________
